Study design and population

A retrospective study was conducted in patients admitted to La Paz University Hospital (a tertiary referral hospital in Madrid, Spain) after they had received treatment with emergency PCI for STEMI, between July 2006 and September 2013. During this period, all patients with STEMI were invited to participate in a cardiac rehabilitation programme and all patients who agreed to participate in the programme were also included in the current study. Patients who did not participate in the cardiac rehabilitation programme were excluded from the current study. The study was reviewed and approved by La Paz Hospital Research Ethics Committee (HULP: PI-1858).

The cardiac rehabilitation programme was an outpatient programme, beginning at least 15 days after the PCI and lasting for 8–10 weeks. The programme comprised 2–3 sessions per week of 90 minutes each and included the following: physical training; educational intervention and a specific smoking cessation follow-up when needed. Physical training included an aerobic exercise programme (60 minutes per session), adjusted to each patient on the basis of functional capacity assessed with a treadmill stress test before the programme, and also strengh training (15 minutes per session), developing from a structured, monitored programme to a more independent, less-monitored programme. The educational intervention (cardiovascular risk factor control, and dietary and pharmacotherapy counselling) was given each visit in 15-minute sessions.

The current study was restricted to patients with STEMI and multivessel coronary disease detected during the emergency PCI procedure. The treatment consisted of either CR or PR, according to a decision made by the interventional cardiologist and clinical cardiologist in charge of the patient during the admission. The retrospective follow-up after hospital discharge included measurement of cardiovascular events (STEMI, non-STEMI, stroke and acute peripheral vascular disease), new PCI, hospital readmissions for cardiovascular reasons and mortality. After the cardiac rehabilitation programme, all patients received clinical follow-up in the cardiology outpatient department, every 6–12 months. If required, cardiovascular emergencies were treated at La Paz Emergency Service. The HORUS platform (Madrid electronic health record) was used to review the electronic medical records of all the patients.

Definitions and clinical outcomes

Coronary artery disease was defined as any epicardial vessel with stenosis > 50%. Simple visual estimation was used to determine the degree of coronary stenosis. Multivessel disease was defined as stenosis > 50% in two or more epicardial coronary arteries. PR was defined as culprit vessel only intervention or culprit vessel plus another artery intervention, leaving at least one diseased coronary artery. CR was defined as multivessel intervention, leaving no diseased coronary arteries; this could be achieved at the time of the primary PCI or staged in time intervals during the admission. The infarct-related artery was treated systematically during the initial intervention; evidence supporting preventive intervention in non-infarct-related lesions is a matter of debate . Multivessel PCI and CR during STEMI was the decision of the clinical cardiologist and the interventional cardiologist in charge of the patient, and was considered in individuals with multiple, critical stenoses or highly unstable lesions (angiographic signs of possible thrombus or lesion disruption), and if there was persistent ischaemia after PCI on the culprit lesion.

During follow-up, a cardiovascular event was established as an acute coronary syndrome with or without ST-segment elevation, stroke or acute peripheral vascular disease. The cardiologist in charge decided if new PCI was to be performed in the patient, for any significant clinical indication. Data on hospital readmissions for cardiovascular reasons were obtained from information included in hospital discharge reports. Data on mortality were obtained from information included in the final medical report of the patient.

Statistical analyses

Patients were divided into two groups: the PR group and the CR group. Non-categorical variables are summarized using means and were compared using Student’s t test. Categorical variables are expressed as percentages and were compared using the χ ² test. Kaplan–Meier curves were plotted for the time to occurrence of clinical outcome and were compared using the log-rank test. Cox proportional hazard models were adjusted for age, sex, presence of diabetes mellitus and number of affected coronary vessels, to estimate the hazard ratios (HRs) of a new cardiovascular event between PR and CR groups. The proportional hazards assumption was checked by the visual appearance of the stratified Kaplan–Meier plots, as well as by testing for a non-zero slope in a generalized linear regression of the scaled Schoenfeld residuals on functions of time. Based on these analyses, a binary time-dependent term (period up to 400 days and period beyond 400 days) was created and the interactions between the latter and the type of revascularization were modelled to allow a different HR for the early and late follow-up periods. A subanalysis was conducted to compare culprit vessel only intervention (a subgroup of the PR group) versus CR. Statistical significance was established at P < 0.05 (two-tailed) for all tests. All statistical analyses were conducted using Stata IC 12.1 (Stata Corp., College Station, TX, USA).

Patients and procedural characteristics

Between June 2006 and November 2013, 1533 patients underwent PCI for STEMI at La Paz University Hospital. Of this patient population, 777 (50.7%) had multivessel disease. Two hundred and eighty-two patients (36.3% of the population with multivessel disease) agreed to participate in the cardiac rehabilitation programme and were enrolled in the study.

In total, 143 patients received PR and 139 received CR (78% of the patients received CR in a staged manner during their hospital admission). Baseline patient characteristics were similar in both groups, except for mean age, which was greater in the PR group (59.3 years vs. 56.7 years in the CR group; P = 0.02) and diabetes mellitus prevalence, which was also higher in the PR group (34.3% vs. 20.1% in the CR group; P = 0.01; Table 1 ).

Table 1

Patient characteristics at baseline.

	PR	CR	P
	( n = 143)	( n = 139)
Age (years)	59.3 ± 10.01	56.7 ± 9.74	0.02
Sex
Male	125 (87.4)	123 (88.5)	0.78
Female	18 (12.6)	16 (11.5)	0.78
Co-morbidities
Hypertension	82 (57.3)	76 (54.7)	0.65
Diabetes mellitus	49 (34.3)	28 (20.1)	0.01
Dyslipidaemia	94 (65.7)	90 (64.7)	0.86
Smoker	75 (52.4)	81 (58.3)	0.32
Obesity	35 (24.5)	39 (28)	0.49
History of
STEMI	21 (14.7)	14 (10.1)	0.24
Stroke	2 (1.4)	2 (1.4)	0.97
Peripheral artery disease	10 (6.9)	11 (7.9)	0.76
BMI	28.1 ± 3.88	27.7 ± 3.77	0.38
STEMI
Anterior	56 (39.1)	43 (30.9)	0.14
Lateral	6 (4.2)	10 (7.2)	0.27
Inferior	81 (56.6)	86 (61.9)	0.37
Arteries with stenosis
2	63 (44.1)	95 (68.3)	0.001
3	71 (49.7)	41 (29.5)	0.001
4	9 (6.3)	3 (2.2)	0.08
Number of arteries with stenosis	2.6 ± 0.67	2.3 ± 0.46	0.001
LVEF (%)	47 ± 14.04	48.3 ± 12.28	0.40

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